“What gets measured gets done,” the saying goes. It’s a fitting one for the state’s new practice of tracking preventable medical errors. In just the fourth year of reporting, Indiana hospitals and surgery centers reported more than a 10 percent decrease in errors between 2008 and 2009.
Indiana’s Medical Error Reporting System requires hospitals, surgery centers, abortion clinics and birthing centers to report “never events,” as in, they should never occur. The errors cover 28 serious events, from surgery performed on the wrong patient to an infant discharged to the wrong person to patient suicide.
Indiana was just the second state after Minnesota to require reporting of the errors, which are defined by the National Quality Forum, a nonprofit group seeking improvements in health-care quality. Just days after taking office in 2005, Gov. Mitch Daniels issued an executive order requiring the Indiana State Department of Health to implement the system.
It’s fair to say some goals of the program already have been met. The reporting system has made Hoosiers more aware of the incidence of medical errors. The goal of analyzing data to learn where errors are being made was realized in the health department’s new initiative to reduce pressure ulcers, also known as bedsores. The state sought to improve systems for assessing risk factors for patients and in training hospital personnel. Just 22 bedsores were reported statewide in 2009, the fewest since reporting began.
Of the 94 preventable errors reported statewide last year, Clarian Health had 18, the highest reported. The health system, which includes Methodist Hospital, Riley Hospital for Children and Indiana University Hospital, is overwhelmingly the state’s busiest hospital system, with 56,022 inpatient discharges and 168,689 outpatient visits.
Fort Wayne’s Lutheran Hospital, with two reportable errors, had 23,548 inpatient discharges and 82,339 outpatient visits. One of the errors was attributed to care management and the other was a surgical error. Lutheran is Allen County’s busiest hospital in terms of procedures, with 45,104 completed last year.
Parkview Hospital, which reported five errors in the first year of statewide reporting, had no errors in 2009. The hospital is Allen County’s busiest in terms of patient numbers, with 26,353 inpatient discharges and 104,371 outpatient visits. Parkview performed 36,772 procedures.
Tracking and preventing errors is a key to reining in health-care costs. The Society of Actuaries reported this month that medical errors cost hospitals $19.5 billion in 2008.
The federal health-care reform package takes a modest step to cutting those costs by requiring Medicare to track a hospital’s error rates. In 2014, the federal government will cut payment by 1 percent to hospitals with the highest rates of patient safety issues. A bolder step, as Indiana has done, would save more.